Prosthetic Heart Valves Treatment & Management

  • Author: Eric M Kardon, MD, FACEP; Chief Editor: David FM Brown, MD   more...
 
Updated: Feb 8, 2010
 

Emergency Department Care

In patients with acute valvular failure, diagnostic studies must be performed simultaneously with resuscitative efforts.

  • Primary valve failure: Patients with valvular failure due to breakage or abrupt tearing of the components usually present with acute hemodynamic deterioration. They need emergent valve replacement. Adjunctive therapy may be initiated while these arrangements are being made. A less dramatic presentation of valvular failure may be seen in patients with valve thrombosis or in those with more gradual deterioration of bioprosthetic valves (see Thromboembolic complications).
    • Begin afterload reduction and inotropic support in order to reduce the impedance to forward flow and improve peripheral perfusion. If the mean arterial pressure is higher than 70 mm Hg, sodium nitroprusside may be used. If the mean arterial pressure is lower than 70 mm Hg, dobutamine alone or in combination with inamrinone may be used.
    • Avoid inotropic agents with vasoconstricting properties.
    • Intra-aortic balloon counterpulsation may be useful in cases of acute mitral regurgitation when the patient is in extremis and surgical facilities are not immediately available. Intra-aortic balloon counterpulsation is relatively contraindicated in the presence of an incompetent aortic valve.
  • Prosthetic valve endocarditis
    • Administer intravenous antibiotics as soon as 2 sets of blood cultures are drawn. Vancomycin and gentamicin may be used empirically pending blood cultures and determination of methicillin resistance.
    • Consider anticoagulation in PVE, since the incidence of systemic embolization is as high as 40%.
    • Consider emergency surgery in patients with moderate-to-severe heart failure or in patients with an unstable prosthesis noted on echocardiography or fluoroscopy.
  • Thromboembolic complications
    • Patients presenting with embolization need to be anticoagulated if they are not already taking anticoagulants or have a subtherapeutic INR.
    • Assessment of valve function is needed.
  • Prosthetic valve thrombosis
    • Surgery had historically been the mainstay of treatment but is associated with a high mortality rate.
    • Mortality rates as high as 20-40% have been reported in those with New York Heart Association (NYHA) class IV.
    • Thrombolytic therapy may be used to treat select patients with thrombosed prosthetic valves.
    • Patients with right-sided prosthetic valve thrombosis (PVT) and those with left-sided PVT and NYHA class III and IV, pulmonary edema, or hypotension may benefit from thrombolysis due to the higher operative mortality.
    • Contraindications to thrombolysis of left-sided prosthetic valve thrombosis include the presence of a large left atrial thrombus, ischemic CVA between 4 hours and 4-6 weeks ago, and very early postoperative state (< 4 d).[8]
    • Thrombolytic therapy should always be done in conjunction with cardiovascular surgical consultation.
    • Thrombolysis is emerging as the treatment of choice in obstructing prosthetic valvular thrombosis.
    • The chance of a successful thrombolysis is inversely related to the size of the thrombus and the amount of time that has elapsed since the onset of symptoms.
    • Outcomes are superior in patients who are relatively stable, although thrombolysis is often performed in patients who are poor surgical candidates.
  • Anticoagulant-related hemorrhage
    • Patients with major anticoagulant-related hemorrhage require reversal of their anticoagulation with fresh frozen plasma and vitamin K.
    • The time off anticoagulants should be as short as possible to avoid valve thrombosis.
    • Use of recombinant factor VIIa or prothrombin complex concentrate should not be used to reverse excessive anticoagulation in patients with prosthetic heart valves.
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Consultations

  • In patients presenting with any degree of prosthetic valvular failure, early consultation with a cardiologist is recommended in order to perform and interpret an echocardiogram.
  • Consult a cardiothoracic surgeon early in cases of severe hemodynamic compromise.
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Contributor Information and Disclosures
Author

Eric M Kardon, MD, FACEP  Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

A Antoine Kazzi  MD, Deputy Chief of Staff, American University of Beirut Medical Center; Associate Professor, Department of Emergency Medicine, American University of Beirut, Lebanon

A Antoine Kazzi is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

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Medtronic Hall mitral valve. Reproduced with permission from Medtronic, Inc.
The Hancock M.O. II aortic bioprosthesis (porcine). Reproduced with permission from Medtronic, Inc.
Starr-Edwards Silastic ball valve mitral Model 6120. Reproduced with permission from Baxter International, Inc.
Carpentier-Edwards Duralex mitral bioprosthesis (porcine). Reproduced with permission from Baxter International, Inc.
Carpentier-Edwards Perimount pericardial aortic bioprosthesis. Reproduced with permission from Baxter International, Inc.
St. Jude Medical mechanical heart valve. Photograph courtesy of St. Jude Medical, Inc. All rights reserved. St. Jude Medical is a registered trademark of St. Jude Medical, Inc.
 
 
 
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